Jugular venous pressure
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The jugular venous pressure (JVP, sometimes referred to as jugular venous pulse) is the indirectly observed pressure over the venous system. It can be useful in the differentiation of different forms of heart and lung disease. Classically three upward deflections and two downward deflections have been described. the upward deflections are the "a" (atrial filling), "c" (ventricular contraction and resulting bulging of tricuspid into the right atrium during isovolumic systole) and "v"= atrial venous filling. and the downward deflections of the wave are the "x"(tricuspid opens and ventricular filling occurs) and the "y" descent reflects filling of ventricle after tricuspid opening.
The interpretation of JVP findings can be challenging and is becoming a lost art, as much of the subtle information previously obtained by careful observation of the JVP can now be gained easily with echocardiography and/or EKG. Certain wave form abnormalities, include "Cannon a-waves", which result when the atrium contracts against a closed tricuspid valve, due to complete heart block (3rd degree heart block), or even in ventricular tachycardia. Another abnormality, "c-v waves", can be a sign of tricuspid regurgitation.
An elevated JVP is the classic sign of venous hypertension (e.g. right-sided heart failure). The paradoxical increase of the JVP with inspiration (instead of the expected decrease) is referred to as the Kussmaul sign, and indicates impaired filling of the right ventricle. The differential diagnosis of Kussmaul's sign includes constrictive pericarditis, restrictive cardiomyopathy, pericardial effusion, and severe right-sided heart failure.
Differential Diagnosis of Elevated Jugular Venous Pressure (Jugular Venous Distension)
- Atrial fibrillation
- Bradycardia
- Cardiac Tamponade
- Cardiomyopathy
- Chronic Obstructive Pulmonary Disease (COPD)
- Right heart failure
- Constrictive pericarditis
- Goiter
- Heart block
- Hodgkin's Lymphoma
- Hyperdynamic circulation (e.g. in extreme anemia)
- Hypervolemia or fluid overlaod
- Mediastinal emphysema
- Mediastinal neoplasm
- Pericardial effusion
- Pulmonary hypertension
- Right atrial myxoma
- Right ventricular dilation
- Right ventricular myocardial infarction
- Superior Vena Cava Syndrome
- Tension pneumothorax
- Thymoma
- Tricuspid regurgitation
- Tricuspid stenosis
- Valsalva maneuver
Jugular vein distention is a classic sign of elevated venous pressure.
The CVP vs the JVP
The central venous pressure (CVP) lies approximately 5 cm above the middle of the right atrium. The CVP is therefore estimated to be the JVP in cm plus 5 cm. Normally the CVP is 5-9 cm of H2O.
Hepatojugular reflux
Hepatojugular reflux, sometimes incorrectly referenced as a "reflex",[1] is an expanded form of the JVP measurement. By pressing on the liver (hepato-) for 15-30 seconds, venous blood is advanced into the circulation. The JVP increases in a normal person, and distention should appear more pronounced. However, a slow decrease of the JVP after checking for hepatojugular reflux can indicate right ventricular failure.
Method
A classical method for quantifying the JVP was described by Borst & Molhuysen in 1952.[1] It has since been modified in various ways.
The patient is positioned under 45°, and the filling level of the jugular vein determined. In healthy people, it is maximum several (3-4) centimetres above the sternal angle. Some doctors employ a venous arc, an instrument to measure the JVP more accurately. A pen-light can aid in discerning the jugular filling level.
Visualization of the JVP
The JVP is easiest to observe if one looks along the surface of the sternocleidomastoid muscle, as it is easier to appreciate the movement relative the neck when looking from the side (as opposed to looking at the surface at a 90 degree angle). Like judging the movement of an automobile from a distance, it is easier to see the movement of an automobile when it is crossing one's path at 90 degrees (i.e. moving left to right or right to left), as opposed to coming toward one. Remember, tangential light is critical.
Differentiation of the JVP from the carotid pulse
Pulses in the JVP are rather hard to observe, but trained cardiologists do try to discern these as signs of the state of the right atrium.
The JVP and carotid pulse can be differentiated several ways:
- multiphasic - the JVP "beats" twice (in quick succession) in the cardiac cycle. In other words, there are two waves in the JVP for each contraction-relaxation cycle by the heart. The first beat represents that atrial contraction (termed a) and second beat the VENOUS FILLING against a closed tricuspid valve (termed v) and not the commonly mistaken 'ventricular contraction'. The carotid artery only has one beat in the cardiac cycle.
- non-palpable - the JVP cannot be palpated. If one feels a pulse in the neck, it is generally the common carotid artery.
- occludable - the JVP can be stopped by occluding the internal jugular vein by lightly pressing against the neck.
- varies with head-up-tilt (HUT) - the JVP varies with the angle of neck. If a person is standing their JVP appears to be lower on the neck (or may not be seen at all because it below the sternal angle). The carotid pulse's location does not vary with HUT.
- varies with respiration - the JVP usually descreases with deep inspiration. Physiologically, this is a consequence of the Frank-Starling mechanism as inspiration decreases the thoracic pressure and increases blood movement into the heart (venous return), which a healthy heart moves into the pulmonary circulation.
- abdominal jugular reflux (AJR) (also hepatojugular reflux) - the JVP changes with abdominal pressure. If the JVP is elevated 4 cm, it usually returns to its baseline level within 10 seconds. If the JVP remains elevated for a longer period of time it suggests heart failure.
JVP waveform
The jugular venous pulsation has a double waveform. The ‘a’ wave corresponds to atrial contraction and ends synchronously with the carotid artery pulse. The ‘c’ wave occurs when the ventricles begin to contract and is caused by bulging of the atrioventricular (AV) valves backwards towards the atria. The ‘v’ wave is seen when the tricuspid valve is closed, just before ventricular contraction – with and just after the carotid pulse. The ‘v’ wave represents the gradual build-up of blood in the atria while the AV valves are closed during ventricular contraction. The absence of ‘a’ waves is a feature of atrial fibrillation.
Components of the JVP Waveform
Abnormalities in the JVP Waveforms
| Absence of a wave | Atrial fibrillation |
| Flutter of a wave | Atrial flutter |
| Prominent a waves | First-degree atrioventricular block |
| Large a waves | Tricuspid stenosis, Right atrial myxoma, Pulmonary hypertension, Pulmonic stenosis |
| Absent x descent | Tricuspid regurgitation |
| Prominent x descent | Conditions associated with large a waves |
| Slow y descent | Tricuspid stenosis, Right atrial myxoma |
| Rapid y descent | Constrictive pericarditis, severe Right heart failure, Tricuspid regurgitation, Atrial septal defect |
| Absent y descent | Cardiac tamponade |
References
External links
- Clinical Examination page on JVP
- JVP (GPnotebook)
- JVP - may not be very useful
- Neck Veins - Merck Manual
Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
